Arthroscopic cannula and suture management system

ABSTRACT

A flexible portal cannula for use in arthroscopic surgery. Distally positioned flaps extend radially outwardly from the outer surface of the cannula and are resiliently foldable to lie against the outer surface of the cannula during insertion into a surgical portal, and resiliently biased to return to the radially outwardly extending position when unconstrained. A clip disposed on the cannula outer surface outside of an arthroscopic workspace acts to clamp tissue disposed between the clip and the flaps. The clip has an extension to receive pairs of slots to sort and engage the sutures.

This application is a continuation of U.S. application Ser. No.17/623,066, filed Dec. 27, 2021, which is a national stage ofInternational Application PCT/US2020/041210, filed Jul. 8, 2020, whichclaims priority to U.S. Provisional Application 62/871,621, filed Jul.8, 2019.

FIELD OF THE INVENTIONS

The inventions described below relate to the field of arthroscopicsurgery and more specifically, to portal access and suture managementduring arthroscopic surgery.

BACKGROUND OF THE INVENTIONS

Arthroscopy is a minimally invasive procedure for treating jointpathology and is a superior alternative to open joint arthrotomy.Arthroscopy has the advantage of less disruption to the joint tissues,and potentially faster healing. The scope of joints and pathologies thatcan be treated with arthroscopy has grown dramatically, and now includeship, spine, and small joint procedures in addition to the traditionalknee and shoulder procedures. However, arthroscopy remains a technicallydemanding procedure, and new instrumentation and procedures areconstantly being developed.

Access to difficult to reach parts of the joint remains a significantchallenge. While curved and flexible instruments are available to accessthese hard to reach areas of the joint, access portal devices have notkept up with the instrument advances. Some attempts have been made todevelop flexible portals, however these have significant drawbackseither in being only slightly flexible, being very difficult to use, orbeing incompatible with standard portal placement techniques andinstrumentation. For example, the Arthrex® PassPort Button Cannula™ is arubbery cannula that provides instrument mobility in shoulderoperations. However, delivery of the device is non-standard, requiringthe surgeon to fold the device in half with a hemostat before insertion.What is needed is an instrument system that allows a high level offlexibility, high instrument mobility, and high ease of use whileretaining compatibility with standard cannula placement techniquesinvolving switching sticks and guide wires.

Suture management is also a challenge in these procedures. In procedureswhere pairs of sutures are used in common double loaded suture anchors,it is possible that the surgeon may tie the wrong pairs of suturestogether, which can require significant extra surgical time and cost, aswell as additional risk and trauma to the patient to correct.

SUMMARY

The systems described below provide for insertion of a flexible portalcannula into a surgical portal, providing better retention of thecannula within the surgical portal. Distally positioned flanges, tabs orflaps extend radially outwardly from the outer surface of the cannulaand are resiliently foldable to lie against the outer surface of thecannula during insertion into an incision, and resiliently biased toreturn to the radially outwardly extending position when unconstrained.Once the cannula is inserted into the workspace, a clip disposed on thecannula outer surface outside of the arthroscopic workspace acts toclamp tissue disposed between the clip and the flaps. Ridges on theshaft of the cannula allow for incremental adjustment of the level atwhich the clip may be secured to effect compression of tissue betweenthe flaps and the clip. The clip can easily be frictionally engaged tothe cannula after insertion to the desired compression.

The cannula clip also features a suture sorter for easier suturemanagement. The clip has pairs of slots to sort and engage pairs ofsutures used in common “double loaded” suture anchors until the suturesare used. These slots may be identified with markings, letters ornumbers that associate the location and orientation of the slots toanatomical locations in the joint.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates an elastomeric portal cannula and driver system withpaired engagement features.

FIG. 2 illustrates the system of FIG. 1 with the driver disposed withinthe elastomeric portal cannula.

FIG. 3 illustrates the system of FIGS. 1 and 2 with a switching stickdisposed within a lumen of a cannulated driver.

FIG. 4 illustrates the cannulated driver.

FIG. 5 illustrates the switching stick.

FIG. 6 illustrates an exploded view of a portal cannula and driversystem having a plurality of gripping features.

FIG. 7 illustrates the system utilizing a plurality of cylindricalgripping features.

FIG. 8 illustrates the mating engagement between the plurality ofcylindrical gripping features and the cannula of FIG. 7 .

FIG. 9 illustrates a cannula with a distal flange and a clip with suturesorting.

FIGS. 10 through 15 illustrate a cannula with a plurality of flapsdisposed on the distal end of the cannula.

FIGS. 16 and 17 illustrate detailed views of the flaps shown in FIGS. 10through 15 .

FIGS. 18 and 19 illustrate flaps disposed on a ring configured to engagethe tube of the cannula.

FIG. 20 illustrates a cannula with webs connecting the flaps to thecannula.

DETAILED DESCRIPTION OF THE INVENTIONS

FIG. 1 illustrates an exploded view of the system for driving a cannulainto a surgical site. The system includes a rigid driver 1, a cannula 2,and a switching stick 3. The driver, as shown in FIGS. 3 and 4 ,comprises a handle 9 attached to the rigid tube 4. The driver may have ahemispherical seal 23. The driver may be cannulated (as shown) throughits core to allow for insertion of the switching stick (FIG. 5 ). Thecannula is delivered into place with the rigid tube 4 that has aninterlocking feature at the distal tip that engages with a matinglocking feature in the distal tip of the cannula. In this way, theproximal portion of the cannula is “pulled” into a surgical portal orincision from its distal tip as the distal tip is pushed. The systemallows for the use of a switching 3, a rod typically about 4 mm indiameter that is used as a guide wire to place a cannula into a surgicalportal. It should be appreciated that the switching stick is an optionalfeature, as is the driver cannulation which accommodates the switchingstick.

FIG. 2 illustrates the system of FIG. 1 when assembled, with the cannuladisposed over the rigid tube 4. The cannula shown has a side port 5 toallow fluid inflow and outflow from the joint, providing fluidmanagement in order to maintain clarity in the joint during thearthroscopic surgical procedure. The cannula has a flexible distalflange 6 or flap to retain the cannula in the joint, preventing it frombacking out of the surgical site. An expandable distal wiper seal 7 maybe provided to hold fluid in the joint and prevent fluid leakage.External retention ridges 8 are disposed over the exterior of thecannula.

In use, the driver is inserted into the proximal end 2P of the cannula 2until the distally extending protrusion 12 at the distal tip 11 of therigid driver engages the mating locking feature in the cannula. When thedriver is engaged, the cannula is supported by the rigid tube. Theswitching stick 3 is inserted through the proximal end 11 of the driver1, through the driver, and out the distal end of the driver and throughthe cannula. The entire assembly comprising the switching stick, rigiddriver and cannula are inserted into the surgical portal or incision.When the cannula is in the desired position in the surgical site, theswitching stick 3 is withdrawn, and then the rigid driver 1 iswithdrawn.

The driver and cannula can have a plurality of engaging features, asshown in FIGS. 6, 7 and 8 . Each of the driver gripping features 12correspondingly mate with detents 13 disposed on the inside wall of thecannula. Rather than one engagement point at the distal tip, theengagement features may be distributed along the length of the cannula.The plurality of engagement features allow the driver to push longer andlower durometer flexible cannulas into a surgical portal. The driver mayhave a uniform diameter. The gripping feature 12 of the driver engageswith a proximally facing shoulder 13 of the cannula as shown in FIGS. 7and 8 .

Generally, the cannula is a flexible portal cannula for use inconjunction with the cannula driver. The cannula driver comprises ashaft having a distal end and a proximal end and at least one distallyextending projection extending from its distal end, or extendingdistally from the outer surface of the driver proximate its distal end.The flexible portal cannula comprises a flexible tube, characterized bya proximal end and a distal end and a lumen extending from the proximalend to the distal end of the flexible tube, and a distal tip on thedistal end. The distal tip of the flexible tube is adapted for insertionthrough a surgical portal into an arthroscopic workspace proximate ajoint in a patient. The flexible tube has a proximally facing groovedisposed on an inner surface thereof, proximate its distal end, which issized and dimensioned to receive a distally extending projection of thecannula driver. The proximally facing groove can be an annular grooveentirely circumscribing the inner diameter of the portal cannula, or itmay extend merely partially around the inner diameter. As illustrated,the groove is most conveniently formed by a ring extending proximallywithin the distal tip of the portal cannula. The ring can be suspendedor fixed to an inwardly protruding flange which protrudes inwardly fromthe inner wall of the portal cannula, but can also be fixed directly to,or depend directly from, the inner wall of the portal cannula. Thedriver may be a solid shaft, but is preferably hollow, with a lumensuitable for passage of a switching stick. Also, the driver may be splitlongitudinally, into two or more elongate sections, to be used inconjunction with a portal cannula having two or more lumens separated bylongitudinally extending webs, where the webs are sized to fit in thespace separating the elongate sections, to provide a system forinserting a multi-lumen portal cannula.

FIG. 9 illustrates a cannula 14 with a distal flange 15 and a clip 16.The flange 15 is resiliently foldable in a proximal direction while thecannula is passed through the surgical incision, and resiliently biasedto return to the radially outwardly extending position after passingthrough the incision and into the arthroscopic workspace. Thecombination of the distal flange 15 and the clip 16 is operable to clampthe tissue disposed between the clip and the flange. The distal flange15 is disposed at the distal end of the cannula and may have one or moreslits 17 that allow the flange to fold back and thus reduce the forceneeded to push the cannula into the workspace. Perforations at the baseof the flange where the flange connects to the outer surface of thecannula may be provided for ease of folding. Alternatively, the flangewith split arrangement can be characterized as separate flaps attachedto the outer surface of the cannula as shown. Ridges 18 on the shaft ofthe cannula allow for incremental adjustment of compression applied bythe clip. The clip 16 is configured to frictionally engage the cannulaand can easily be slipped onto the cannula after insertion to thedesired compression. The clip 16 can be positioned, relative to theflange 15, to compress intervening tissue.

The cannula clip 16 features an extension 13 for sorting sutures. Theextension 13 sorts and engages sutures coming out of a shoulder during arotator cuff repair or any repair procedure involving sutures. The clip16 has an extension 13 for sorting and arranging sutures for theconvenience of the surgeon, consisting of a plurality of slots 19 aroundthe perimeter of the extension 13 of the clip 16. The extension 13 haspairs of slots 19 to sort pairs of sutures used in common double loadedsuture anchors, to keep the sutures neatly out of the way of othertools, and conveniently held for retrieval. In this way the surgeon canavoid tying the wrong pairs of sutures together, which can requiresignificant extra surgical time and cost, as well as additional risk andtrauma to the patient to correct. These slots 19 may be identified withmarkings, letters or numbers that associate the location and orientationof the slots to anatomical locations in the joint. An example of suchidentifying marks is the “clock” nomenclature for identifying anatomiclocations on the shoulder glenoid, for example 12:00, 3:00, 6:00, and9:00. The slots can be tapered to grip different diameters of sutures.The slots can be “L shaped” (as shown in FIG. 10 ) to cleat the sutureand keep the sutures from slipping out of the slot 19.

FIGS. 10 through 17 show an embodiment with a plurality of flaps or tabs20 which fold back when the cannula is inserted into the incision. Inthe embodiment shown there are four separate tabs, but any plurality oftabs may be provided. The tabs 20 are disposed at the distal end of thecannula, proximate the distal tip 11, and extend radially outwardly fromthe outer surface of the cannula. Each tab has a root 21 and a tip 22,with the root 21 at a first end nearest to the cannula outer surface andthe tip 22 at the second end of the tab furthest from the cannula outersurface. The root is the part of the flap immediately adjacent to thecannula. As shown in FIG. 16 , the root has a width dimension B, that issmaller than the tab face width, dimension A, so that the force ofinsertion into a portal will cause each tab to fold back.

Each flap includes a root portion proximate the outer surface of thecannula, a radially outward portion radially outward of the root, and aproximal face and a distal face, wherein the root portion spans a firstcircumferential arc (dimension B) and the radially outward portion spansa second circumferential arc (dimension A) larger than the firstcircumferential arc. The root portion of each flap has a first thicknessD, and in the radially outward portion each flap has a second thicknessC greater than the first thickness D, as shown in FIG. 17 . The tabs arearranged circumferentially around the distal end of the cannulaproximate the distal tip. The tabs are made of a flexible material.

Distally positioned flaps or tabs 20 extend radially outwardly from theouter surface of the cannula and are resiliently foldable in a proximaldirection while passing through the surgical portal, to lie against theouter surface of the cannula, and resiliently biased to return to aradially outwardly extending position when unconstrained when the distaltip of the cannula is within the arthroscopic workspace.

FIGS. 18 and 19 show an embodiment in which the tabs are disposed on aring 24 that mounts onto the body of a cannula. The cannula 25 has aretaining groove 26 for matable attachment to a ring 24. The tabs 27 aredisposed circumferentially around the ring. The matable attachment ofthe ring 24 and cannula 25 may be via retaining groove 26, screw,snap-fit or other means.

FIG. 20 shows an embodiment with two tabs or flaps 28 disposed on thedistal end of the cannula 29 in opposition to each other. Each flap hasa proximal face, which is the face closest to the cannula proximal end,and a distal face. Each flap has a flexible web 30 provided on theproximal face of the flap connecting the proximal face of the tab to theouter surface of the cannula. The flaps fold inward toward the outersurface of the cannula when the cannula is being inserted into theincision and resiliently return to the original unconstructed orextended position when the flaps are placed within the arthroscopicworkspace. The webs maintain the flaps in the extended position.

While the preferred embodiments of the devices and methods have beendescribed in reference to the environment in which they were developed,they are merely illustrative of the principles of the inventions. Theelements of the various embodiments may be incorporated into each of theother species to obtain the benefits of those elements in combinationwith such other species, and the various beneficial features may beemployed in embodiments alone or in combination with each other. Otherembodiments and configurations may be devised without departing from thespirit of the inventions and the scope of the appended claims.

1. A cannula for use in arthroscopic surgery, said cannula comprising; acannula tube, said cannula tube having a proximal end, a distal end, anda lumen extending therethrough, and a distal tip on the distal end, saiddistal tip configured for insertion through an incision into anarthroscopic workspace, proximate a joint in a patient; a plurality offlaps disposed on the distal end of the tube, proximate the distal tip,said flaps extending radially outwardly from an outer surface of tube,said flap resiliently foldable in a proximal direction when constrainedwhile passing through the incision, to lie against the outer surface ofthe tube, and resiliently biased to return to a radially outwardlyextending position when unconstrained; and wherein each flap ischaracterized by a root portion proximate the outer surface of thecannula, a radially outward portion radially outward of the root, and aproximal face and a distal face, wherein said root portion spans a firstcircumferential arc and the radially outward portion spans a secondcircumferential arc larger than the first circumferential arc.
 2. Acannula for use in arthroscopic surgery, said cannula comprising; acannula tube, said cannula tube having a proximal end, a distal end, anda lumen extending therethrough, and a distal tip on the distal end, saiddistal tip configured for insertion through an incision into anarthroscopic workspace, proximate a joint in a patient; a plurality offlaps disposed on the distal end of the tube, proximate the distal tip,said flaps extending radially outwardly from an outer surface of tube,said flap resiliently foldable in a proximal direction when constrainedwhile passing through the incision, to lie against the outer surface ofthe tube, and resiliently biased to return to a radially outwardlyextending position when unconstrained; and wherein each flap ischaracterized by a root portion proximate the outer surface of thecannula, a radially outward portion radially outward of the root, and aproximal face and a distal face, wherein, in the root portion, each flaphas a first thickness, and in the radially outward portion each flap hasa second thickness greater than the first thickness.
 3. The cannula ofclaim 2, wherein: said root portion spans a first circumferential arcand the radially outward portion spans a second circumferential arclarger than the first circumferential arc.
 4. The cannula of claim 2,further comprising; a clip configured for a friction fit on the cannulatube, whereby, in conjunction with the flaps in the radially outwardlyextending position when unconstrained and disposed within arthroscopicworkspace, and with the clip disposed on the cannula tube outside thearthroscopic workspace, to clamp tissue disposed between the clip andthe flaps.
 5. The cannula of claim 2, wherein: each flap ischaracterized by a proximal face and a distal face, said cannula furthercomprising a flexible web disposed on the proximal face of the flap andoperably connecting the proximal face of the tab to the outer surface ofthe cannula tube.
 6. The cannula of claim 2 wherein said flap is furthercharacterized by a tip portion, wherein the tip portion is radiallyoutward of the radially outward portion, wherein said tip portion spansa third circumferential arc, said third circumferential arc is smallerthan the second circumferential arc.
 7. The cannula of claim 6 whereinsaid flap is further characterized by a tip portion, wherein the tipportion is radially outward of the radially outward portion, whereinsaid tip portion spans a third circumferential arc, said thirdcircumferential arc is smaller than the second circumferential arc. 8.The cannula of claim 1, wherein: in the root portion, each flap has afirst thickness, and in the radially outward portion each flap has asecond thickness greater than the first thickness.
 9. The cannula ofclaim 1, further comprising; a clip configured for a friction fit on thecannula tube, whereby, in conjunction with the flaps in the radiallyoutwardly extending position when unconstrained and disposed withinarthroscopic workspace, and with the clip disposed on the cannula tubeoutside the arthroscopic workspace, to clamp tissue disposed between theclip and the flaps.
 10. The cannula of claim 1, wherein: each flap ischaracterized by a proximal face and a distal face, said cannula furthercomprising a flexible web disposed on the proximal face of the flap andoperably connecting the proximal face of the tab to the outer surface ofthe cannula tube.
 11. The cannula of claim 1 wherein said flap isfurther characterized by a tip portion, wherein the tip portion isradially outward of the radially outward portion, wherein said tipportion spans a third circumferential arc, said third circumferentialarc is smaller than the second circumferential arc.
 12. The cannula ofclaim 11 wherein said flap is further characterized by a tip portion,wherein the tip portion is radially outward of the radially outwardportion, wherein said tip portion spans a third circumferential arc,said third circumferential arc is smaller than the secondcircumferential arc.